Cheerleading is the number one cause of traumatic injuries for high school and college females. The AMA’s decision follows a similar ruling in 2012 ruling by the American Academy of Pediatrics, and highlights growing worries in the medical community as the activity evolves from simple sideline cheers to performance of gravity-defying stunts more akin to gymnastics.

From 1982 to 2011, according to National Center for Catastrophic Sports Injury Research, high school cheerleaders had 83 severe or disabling injuries, including two that were fatal. Frederick O. Mueller, head of the center, thinks the actual rate of injury is much higher as incidents often go unreported in the unregulated world of cheerleading.

Mueller told the Washington Post the numbers translate into a rate of 2.68 catastrophic injuries for every 100,000 female high school cheerleaders, compared with 1.96 injuries per 100,000 for high school boys football over the same period.

“This tells you that cheerleading is dangerous—even more dangerous than football when it comes to the rate,” Mueller said.

But is cheerleading really a “sport”? Depends who you ask.

Legally, it’s not. The Second U.S. Circuit Court of Appeals in 2012 upheld a previous ruling that cheerleading did not meet the requirements to be considered a sport under Title IX, the 1972 federal law that requires equal opportunity for males and females in athletics.

“With better organization and defined rules, [cheerleading] might someday warrant recognition as a varsity sport. But, like the district court, we conclude that the record evidence shows that ‘that time has not yet arrived,’” the court said in its ruling.

But proponents argue that defining cheerleading as a sport would create better organization, regulations and, importantly, better training for coaches. More than 30 states now recognize cheerleading as a high school sport, most recently Texas last week.

Coaches are often chosen because of prior experience as cheerleaders themselves, says Krista Robinson, executive director of the National Cheer Safety Foundation. But the activity has evolved faster than proper training and safety for coaches. “In addition to being trained in CPR and first response, a coach should also be trained in the body mechanics behind the stunts, tumbling, and critical height. And I bet a good 95 percent of coaches don’t even know what critical height is, and yet their flyers are thrown 10-20 feet in the air. Clearly, that is not safe,” Robinson recently said.

In a detailed analysis of cheerleading safety for FiveThirtyEight, Walt Hickey notes that unlike all other activities, most injuries in cheerleading happen in practice rather than during a game. Part of the problem is that rehearsal space appears to be “all over the place They’re occurring on asphalt, on grass, on tile,” safety expert Dawn Comstock told Hickey. “And if you think about it, if cheerleading isn’t considered a sport, [it] may not be afforded the same resources—even for practice—as other sports.”

Underlining the debate is money. More resources for cheerleading would improve safety, but requires school systems to make tough choices with a limited pool of cash. The Title IX lawsuit was spurred when players and their coach sued after Quinnipiac University decided to cut girls volleyball and replace it with a competitive cheer squad for budgetary reasons.

A sports designation can help school systems cover insurance liability for catastrophic cheerleading injuries. But as a sport, cheerleading would find itself in competition with other school activities for money.

In New York State, which recently approved cheerleading as a sport, coach Justina Grudzinski worries that as cheerleading becomes an official school team and part of the school budget, it is also at risk during cutbacks. “Now cheerleading doesn’t cost my district hardly anything” but a coach’s stipend, she told the Wall Street Journal. “Right now we fly under the radar.”

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